Theme 5. Coordinating care to create better transitions

 

Presentation Details

• Date: 10/17/2016
• Concurrent Session C
• Time: 4:30pm – 5:15pm
• Room: Pier 9
• Style: Presentation (information provided to audience, with opportunity for audience to ask question)
• Focus: Balance between both (e.g. Presentation of a best-practice guideline that combines research evidence, policy issues and practical steps for implementation)
• Target Audience: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers, Representatives of stakeholder/partner organizations

Learning Objectives

1. Learn about ER and Hospital usage data specifically for patients with IDD from a province-wide study completed in 2015. Characteristics of this population contributing to high use and complexity will be reviewed
2. Learn about coordination tools designed specifically for patients with IDD:
   1. a guide to CCP completion
   2. an adapted CCP template
   3. a Health Passport to ensure safety in emergencies
   4. a standardized set of IDD specific preventative care recommendations
3. Review a logic model designed to evaluate a health links approach to care coordination and intersectoral/interministerial collaboration for supporting complex, vulnerable populations

Summary/Abstract

Health Links is an Ontario initiative that brings together local healthcare providers to redesign an enhanced coordinated model that is patient-centered for the purpose of improving outcomes for the most complex patients in our region. We will discuss a unique approach which brings MOHLTC health system coordination capacity together with the MCSS developmental service sector’s IDD expertise and ability to identify those most complex and in need.  The presentation will review recently developed tools that support targeted care coordination (Health Link) to this particular population. Such tools include a CCT template  to cover communication and behavioural issues, a Health Information Passport to ensure safety and communication in emergency situations as well as a standardized set of IDD specific preventative care recommendations for primary care teams. It is anticipated that these approaches may be generalized to targeted care coordination of other vulnerable  populations in need of tailored approaches.

Presenters

• Linda Robb Blenderman, RN, BScN, Msc, Kingston Health Link Project Coordinator
• Marg Alden, Lead Agency Representative, Kingston Health Link
• Liz Grier, MD, CCFP, Queen’s Department of Family Medicine
• Ian Casson, MD, CCFP, Queen’s Department of Family Medicine
• Laura Cassidy, Quality Improvement Decision Support Specialist, Kingston Health Link

Authors & Contributors

• Margaret Gemmill, MD, CCFP Queen’s Department of Family Medicine
• Mary Martin, Research Assistant, Queen’s Department of Family Medicine
• Dr Yona Lunsky, Director of H-CARDD and Clinician Scientist at the Centre for Addiction and Mental Health
• Janet Durbin, Project Evaluation Lead, Independent Scientist – Provincial Support Services Program at the Centre for Addiction and Mental Health
• Richelle Uens, Health Care Facilitator, Networks of Specialized Care (MCSS)